Diagnostic and therapeutic process and prognosis in suspected lung cancer.

Survival rates of patients with lung cancer are poor in Denmark and worse than in the other Nordic countries. The study focuses on the diagnostic process, the selection for operation, prognostic factors and outcome in lung cancer. The study comprised 467 consecutive patients with cancer-suspect lesions. In 40% of cases the diagnostic delay exceeded 30 days. Fibreoptic bronchoscopy and fine-needle biopsy (FNB) were the most important diagnostic tests, with approximately 90% accuracy in central and peripheral lesions. FNB of peripheral lesions diagnosed benign histology or small cell lung cancer (SCLC) in 16 patients, and due to that procedure a thoracotomy was prevented. Surgery was performed on 83 (33%) of 252 patients with non-small cell lung cancer. Three-year survival was 37% in all surgically treated patients and 64% after radical operation; 59% of the patients with stage I tumours were alive after three years, but none with stage IV at diagnosis. Among patients operated on, preoperated forced expiratory volume (FEV1) was related to survival rate. Survival rates were higher in women than in men with or without surgery. Of 43 patients with SCLC, 32 received chemotherapy, and half of these were alive after one year. Conclusions from the study were that diagnosis should be speeded up and that diagnostic FNB of peripheral lesions is of value for preventing unnecessary operations. Standard registration of tumour, node, metastasis (TNM) classification, resection, FEV1 (% of predicted) and gender could increase the validity of international comparisons.

[Diagnostic procedure in patients with suspected lung cancer. Results of combined evaluation by thoracic surgery and pulmonary medicine specialists]. / Den diagnostiske proces hos patienter mistaenkt for lungekraeft. Resultaterne af foelles thoraxkirurgisk-lungemedicinsk visitation.

During the last 50 years, the 5-year survival of lung cancer patients has been unchanged at 5%. As the prognosis for patients with operable nonsmall cell lung cancer (NSCLC) is much better, the diagnostic examination of tumour suspicious lesions with secondary judgement of operability in NSCLC is an important subject. This study focuses on the diagnostic process. During the years 1991-1993, 467 consecutive patients with pulmonary tumour suspicious lesions were prospectively followed at the Department of Pulmonary Medicine and the Department of Thoracic Surgery, Bispebjerg Hospital. In 40% of the patients, the diagnostic delay was longer than 30 days. Fiberbronchoscopy and fine needle biopsy were the most important diagnostic tests with an accuracy of approx. 90% for both central and peripheral lesions. Benign lesions comprised 19% of all, while the prevalence of squamous cell carcinoma, adenocarcinoma, small-cell carcinoma and large-cell carcinoma was respectively 21%, 26%, 15% and 18% of the malignant infiltrates. Histological diagnosis was not achieved in 104 patients. Histological diagnosis was achieved in most patients, but the diagnostic process was slow. A faster diagnostic process is to be aimed for and can, hopefully, be achieved by accomplishing diagnostic standards as just proposed by the Danish Lung Cancer Group.

[Therapeutic and prognostic course in patients with suspected lung cancer. Results of combined thoracic surgery-pulmonary medicine evaluation]. / Det terapeutiske og prognostiske forløb hos patienter mistaenkt for lungekraeft. Resultaterne af foelles thoraxkirurgisk-lungemedicinsk visitation.

Survival of patients with lung cancer is poor in Denmark and worse than in the other Nordic countries. The study focuses on the treatment, the selection for operation, prognostic factors and the prognosis in lung cancer. During the years 1991-1993, 467 consecutive patients with pulmonary tumour suspicious lesions were prospectively followed at the Departments of Pulmonary Medicine and Thoracic Surgery, Bispebjerg Hospital, Copenhagen. Operation was performed in 83 (33%) of 252 patients with non-small-cell lung cancer. More than 70% of the 169 non-operated patients were judged inoperable on the basis of a clinical examination and a chest x-ray. The initial estimation of operability, done by the chest physician, was able to predict 91% of the inoperable patients. Therapeutic delay (diagnosis-operation) was on average 26 days and 95% were operated within 60 days. Three-year survival for all the operated patients was 36%, while 62% were alive when they were judged radically operated. For stage I tumours, 51% were alive after three years, while all with stage IV tumours were dead. In the operated patients, lung function was positively related to survival (p = 0.013). Females had a better survival than males (p = 0.01 for operated, p = 0.02 for non-operated). Among 43 with small-cell lung cancer, 32 were treated with chemotherapy, and half of these were alive after one year. Preoperative histology in peripheral lesions is of value in preventing unnecessary operations without significant losses. Mediastinoscopy should be performed before operation. Registration of TNM stage and lung function should become standard in order to make comparison from country to country more valid.

Cellular profiles in bronchoalveolar lavage fluid of HIV-infected patients with pulmonary symptoms: relation to diagnosis and prognosis.

Bronchoalveolar lavage (BAL) cell differentials and T-lymphocyte subpopulations were analysed in 95 HIV-infected patients with pulmonary symptoms to determine whether the type of cellular inflammatory response could be useful in diagnosis or as a prognostic marker. Patients with Pneumocystis carinii pneumonia (PCP) had more BAL fluid lymphocytes, mainly comprising CD8+ cells, and patients with bacterial infection had more neutrophils than other patients. Neither of these changes were mirrored in peripheral blood. Seven patients who died after their acute episode of PCP had significantly higher BAL fluid neutrophils than 53 patients with PCP who survived (P = 0.002). There seems to be correlation between BAL fluid neutrophilia, PCP and concomitant bacterial infection since four out of seven patients with a fatal outcome had coinfection with bacteria, whereas only one patient with PCP and bacterial coinfection survived (P = 0.0007).

Computed tomography and the TNM classification of lung cancer.

Computed tomography (CT) of the thorax and upper abdomen was prospectively evaluated in 84 patients with potentially operable lung cancer. Invasion into the thoracic wall and the mediastinal structures was not accurately demonstrated by CT. For metastatic mediastinal lymph nodes, the sensitivity and specificity of CT were, respectively, 86% and 61% and the positive and negative predictive indices 49% and 91%. For T1, T2 and T3 tumours the negative indices were 100%, 96% and 71%. Positive predictive index did not differ between squamous cell carcinoma and adenocarcinoma. Adrenal metastases were CT-suspected in 17 cases and liver metastases in eight, but were verified by ultrasonography in only one and four cases. CT should be used in preoperative investigation of lung cancer, irrespective of stage. Demonstration of thoracic-wall or mediastinal invasion need not exclude tumour resection. Preoperative mediastinoscopy is indicated if CT shows nodal metastases or if there are signs of tumour invasion, but not in CT-negative T1 or T2 tumour. Abdominal metastases indicated by CT should be investigated with CT-guided needle biopsy.

Fiberoptic bronchoscopy and bronchial mucosal biopsies in asthmatics undergoing long-term high-dose budesonide aerosol treatment.

Mucosal biopsies from the pharynx, right main stem bronchus and right lower lobe were obtained during flexible fiberoptic bronchoscopy and were examined with light microscopy (LM) and electron microscopy (EM) in 10 asthmatics after 11 months' (range 7-15 months) treatment with high doses of inhaled budesonide via the Nebuhaler, i.e. 1600 micrograms daily. Results were compared with biopsies from 10 controls suspected of having focal, malignant lung diseases. Visual inspection of the tracheobronchial tree showed no signs of atrophy, ulcerations or thrush patches, and LM and EM showed no specific signs of mucosa and connective tissue atrophy; however, epithelial desquamation was seen in the asthmatics. No complications were observed.

Transhiatal esophagectomy without thoracotomy.

Twenty patients with cancer of the esophagus and/or cardia underwent transmediastinal esophagectomy by blunt dissection without thoracotomy. Resection and reconstruction with gastroesophageal anastomosis was performed in a single stage in 13 cases. The tumor was nonresectable in seven cases, and instead a substernal bypass was performed. The technical maneuvers are described, and the results and possible advantages and disadvantages of the transhiatal method are discussed.

Transcarinal mediastinal needle biopsy compared with mediastinoscopy.

A total of 183 patients with abnormalities on the chest roentgenogram were examined by bronchoscopy in conjunction with transcarinal mediastinal needle biopsy and mediastinoscopy to investigate the agreement between these methods regarding possible metastases. In 37 of the 159 patients with malignant pulmonary lesions, needle biopsy demonstrated metastases in the subcarinal lymph nodes. Mediastinoscopy had the same percentage of positive findings in the subcarinal nodes, but there was only agreement between the two methods in 20 cases. Transcarinal mediastinal needle biopsy as a supplement to conventional bronchoscopy is applicable in the outpatient evaluation of patients with malignant bronchial lesions as a screening for further examination. The method does not carry complications of any kind. Positive biopsy results, combined with other clinical findings, can at times spare the patient a mediastinoscopy. On the other hand, an adequately indicated needle biopsy which yields negative findings should always be followed by mediastinoscopy. In the planning of treatment for patients with malignant lesions of the lungs, it is of decisive importance to evaluate the dissemination of the tumor to the mediastinal structures, primarily to the subcarinal and the contralateral lymph nodes.

Perforation of the esophagus. Experience from a department of thoracic surgery.

A series of 39 patients treated for perforation of the esophagus in a department of thoracic surgery is presented and discussed. All but three of the lesions arose from instrumentation within the esophagus. The treatment was mainly operative. There were no deaths among the nine patients with perforation of the cervical esophagus, but the mortality was 63% in the patients with thoracic lesions, partly as a result of frequent presence of serious disease in other organs. The authors stress the importance of more rigorous attention during intra-esophageal instrumentation to early detection and treatment of perforation.

Bronchopleural leakage treated with fibrin sealant and high-frequency positive-pressure ventilation.

In a 62-year-old man, left spontaneous pneumothorax appeared 14 days after right pneumonectomy. The large air leakage necessitated thoracotomy and resection of a bullous area in the left upper lobe. Pleurectomy was not performed. The air leakage continued for 14 more days until, at a second left thoracotomy, numerous bullae were oversewn and covered with fibrin sealant. High-frequency positive-pressure ventilation (90 respirations/min, 21 l/min) was used for the following 6 hours. After 18 hours there was no more air leakage during spontaneous ventilation and the patient made a good recovery.